Late diagnosis of proximal radial epiphysis dislocation: case report and literature review

Abstracts

Os autores apresentam um caso de descolamento traumático da epífise proximal do rádio, diagnosticado 5 meses após luxação posterior do cotovelo, em uma criança com 9 anos de idade. Foi realizado redução e fixação da epífise avascular na metáfise proximal do rádio e, após 24 meses de seguimento, esta epífise encontrava-se revascularizada e o cotovelo apresentava flexão de 0-130º, pronação de 80º e supinação de 30º.

ARTIGO ORIGINAL

Late diagnosis of proximal radial epiphysis dislocation. Case report and literature review

William Dias Belangero^I; Bruno Livani^II; Alessandro Janson Angelini^III; Rodrigo Bezerra Tenório^IV

^IProf. Dr. Department Coordinator of DOT/HC/UNICAMP

^IIPost-Graduate student and Orthopedic Surgeon of DOT/HC/UNICAMP

^IIIPost-Graduate student and Orthopedic Surgeon of DOT/HC/UNICAMP

^IVResident 3^{rd. year}

SUMMARY

A case of traumatic dislocation of proximal radial epiphysis is reported, which was diagnosed 5 months after a posterior dislocation of the elbow in a 9 years old girl. Open reduction and fixation of the avascular epiphysis to the metaphysis was performed, and after 24 months follow-up the physis was vascularised and flexion ranged from 0-130°, pronation 80° and supination 30°.

INTRODUCTION

Traumatic dislocation of proximal radial epiphysis (DPRE) represents 4.5 to 21% of all elbow fractures in children. ^(1,3,5,6,8) Landin and Danielsson (1986) reported that elbow fractures have an annual average incidence of 12/10,000 patients under 16, and 14% are related to the proximal radial region. ⁽⁷⁾. These lesions use to occur in children between 2 and 16 years old, with peak incidence around the age of 8 to 11. ^{(1,3,6,7,8,11,14,15)}. There is not a gender predominance ⁽⁷⁾, however in girls this lesion happens earlier. ⁽¹⁵⁾

From an anatomical point of view, these lesions involve the proximal radial physis, producing lesions classified as Salter-Harris II and, less frequently, Salter-Harris I. Fractures involving articular face of radial head are rare in children. ^(6,11,14,15). The most usual mechanism of lesion is a fall with the fist in dorsi-flexion, with stretched elbow and supinated forearm, resulting in a valgus deformity and compression of radial head against the humeral capitulus. ^{(1,3,4,9,12,13,14,)} Associated lesions, as colateral-medial ligament with or without posterior dislocation of the elbow joint occur in 30 to 50% of the cases. ^{(1,3,8,10,14)} When DPRE occurs in association to posterior dislocation of the elbow joint, the radial head usually remains anterior, while, when linked to the reduction maneuver, posterior. ^(4,11,13). The objective of this report is to report the results of the treatment of a late diagnosed traumatic dislocation of proximal radial epiphysis.

CASE REPORT

A 9 years old girl was reported to the Orthopedics and Traumatology Service with a 5 months history of stiffness and pain in the left elbow. Her parents reported that after a fall the child presented pain and swelling in the right elbow. Seen at an other orthopedic center, underwent radiographic examination and was diagnosed with an elbow contusion. Was submitted to immobilization of the elbow in a plaster splint for 8 days and in sequence sent to 40 sessions of physiotherapy without functional improvement.

Evaluated at our service after this period, the child still complained of severe pain and had the elbow in a 30 degree flexion position, allowing movement until 90 degree, pronation of 80 and supination of 0 degree (Table 1). Initial radiographic examination, performed after the accident, presented a traumatic displacement of the proximal radial epiphysis (Figure 1).

An open reduction was performed through a lateral Kocher approach, with a direct reach of the joint, which presented with abundant fibrous tissue. The proximal radial epiphysis was displaced and desvitalized. We opted for preserving it, performing a reduction and fixation through 1.5 mm Kirschner wires placed crossing the capitulus, due to great instability observed during the open reduction (Figure 2). An immobilization in a plaster cast was maintained during 6 weeks, when the Kirschner wires were removed, and the child sent to intensive physiotherapy treatment.

At the end of the first year follow-up, a MRI examination of the elbow was performed, showing revascularization of the proximal radial epiphysis, with a premature closing of the growth plate. (Figure 3)

Currently with 24 months follow-up, the child has no symptoms, with a flexo-extension movement range of 0-130 degree, pronation 80º and supination 30º (Figure 4).

DISCUSSION

Radiological diagnosis of DPRE, as well as other elbow lesions in children are difficult, and can also be misdiagnosed due to the absence of ossification or incomplete ossification of the epiphysis. In general, these lesions can more safely be diagnosed starting from the third year of age, when the proximal radial epiphysis nucleus starts its ossification. When there is doubt, it is always recommended to compare to a radiographic exam of the opposite side. However, even when appropriately diagnosed, these lesions involving the proximal radial epiphysis can lead to a high incidence of complications (20 to 50%) as stiffness, avascular necrosis, premature closing of the growing plate, peri-articular ossification, pseutoarthrosis, malunion, radio-ulnar synostosis and cubito valgus. ^{(1,3,4,7,10,11,14,15)} Whether or not these complications will occur, is dependent on the intensity of the initial trauma, if the growing plate was or not injuried and, mainly, the kind of treatment performed. ^(8,11,15) According to the degree of deviation, and age of the patient, the current trend is to a closed treatment since it allows better results. In children under 5 years old, the accepted deviation can reach 50º, between 5 and 10 years old, should not be above 30º and in girls above 12 years old, and boys above 14, should not exceed 15º. ⁽⁴⁾. In this case, the deviation was not possible to evaluate, since the epiphysis was by the side of the proximal radial metaphysis, without any anatomical link to it. In these circumstances, the reasonable doubt would be to preserve or not the avascular epiphysis. However, it was decided to keep it, since in the literature the results are consistently bad when it is decided to remove it, with more than 50% chance of development of a proximal radio-ulnar synostosis, progressive valgus deformity of the elbow, and distal radio-ulnar dislocation ⁽²⁾. The result that was obtained, not only validates the decision, as well as demonstrates that this procedure is justifiable, since, even avascular, the epiphysis had an important function as a biological spacer while not revascularized and incorporated to the radial proximal metaphysis. It is however necessary to keep this child under follow-up in order to detect any possible abnormality which can happen due to the absence of growth at the proximal growth plate, which, despite contributing to the growth at a lesser extent than the distal one, is responsible for up to 25% of the radial growth.

CONCLUSION

Even though the proximal radial epiphysis was completely separated of the radius for a period of 5 months, its reduction allowed its revascularization, and incorporation into the proximal metaphysis, and consequently, allowed the elbow to be functionally recovered.

REFERÊNCIAS

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Publication Dates

• Publication in this collection
  20 Feb 2006
• Date of issue
  Sept 2001